Provider Demographics
NPI:1033977830
Name:BRANNATA WELLNESS LLC
Entity Type:Organization
Organization Name:BRANNATA WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:DODIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-816-1049
Mailing Address - Street 1:545 SW 2ND ST STE 201
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4466
Mailing Address - Country:US
Mailing Address - Phone:541-816-1049
Mailing Address - Fax:
Practice Address - Street 1:78 N COOPER RD STE 104
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-5210
Practice Address - Country:US
Practice Address - Phone:541-816-1049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty